Expanding Access to ART in Thailand:
Achieving Treatment Benefits while Promoting Effective
Prevention
Joint Study by
Thailand Ministry of Public Health
and
The World Bank*
EXECUTIVE SUMMARY
Thailand is in the vanguard of developing countries that are seeking to provide anti-retroviral
therapy as the standard of care to large numbers of people with symptomatic HIV disease. As of
February 2005, some 52,593 people living with HIV/AIDS in Thailand had received ART
through the National Access to Antiretroviral Program for People Living with HIV/AIDS (or
NAPHA), and approximately 8,000 are estimated to have access to ART through the Social
Security Scheme. The Royal Thai Government’s objective is to provide ART to 80,000 people
living with HIV/AIDS by end-2005.
The purpose of this report is to advise the Thai government and Thai society at large on the full
range of benefits, costs and consequences likely to result from decision to expand public
provision of ART through NAPHA and to assist with the design of implementation policies that
achieve maximum treatment benefits, while promoting prevention and maintaining financial
sustainability.
I. Background
Provision of ART in Thailand
The first case of AIDS in Thailand was reported in September 1984. Since then more than one
million Thais have been infected with HIV and, of these, more than 400,000 have died. In 2004,
some 572,500 Thais were estimated to be living with HIV/AIDS (Table 1). Among these, some
49,500 will develop serious AIDS-related illnesses this year, and about the same will die of
*
Study team includes Thanprasertsuk S., Lertpiriyasuwat C., (MOPH); Revenga A., Over M., Masaki E.,
(World Bank); Brown T., Peerapatanapokin W., (East-West Center); Tangcharoensathien V.,
Lertiendumrong J., (IHPP); Gold J., Duncombe C., (HIV-NAT, Thai Red Cross), Wilson D., (MSF),
Phongphit S., (Village Foundation).
** For questions or clarifications, please contact arevenga@worldbank.org or emasaki@worldbank.org
1
AIDS-related complications. It is also estimated that 19,500 new infections will occur this year
(compared to 143,000 new infections in 1990, and 23, 676 new infection in 2002).
Table 1: Estimated Cumulative Numbers of HIV/AIDS in the year 2004
Total HIV infections (adults and children)
Total deaths (adults and children)
People living with HIV
Projected new HIV infections in 2004
Projected new AIDS cases in 2004
Source: Working Group on HIV/AIDS Projections for 2004.
1,074,155
501,600
572,484
19,471
49,542
The Royal Thai Government and Thai
Figure 1: Access to HIV/AIDS Medical Care
society have demonstrated a strong
commitment to providing comprehensive
Access to HIV/AIDS Medical Care
care and support to persons living with
in Thailand
Thailand
HIV/AIDS (PHAs), but it is only recently
Treatment of common opportunistic infections as TB, PCP, cryptococcal meningitis
etc.
that they have been able to provide
antiretroviral therapy (ART) to large
Monotherapy (AZT) 1992- 1995
numbers of people with symptomatic HIV
Dual therapy (AZT+ddI and AZT+ ddC) 1995 - 1996
(Figure 1). The availability of a
HIV Clinical Research Network (dual and triple ARV) 1997-2000
domestically-produced triple drug
combination (GPO-vir 1) at affordable
Access to care (triple ARV and OI prevention and treatment) since 2000
prices (about 1,200 Baht or US$30 per
National Access to ARV for PWHA since 2003
month) has opened the door for many
PHAs, who could previously not afford it,
to access ART, and has allowed the
Ministry of Public Health to roll-out a
large-scale campaign to provide triple-drug ART as standard care. As a result, the number of
PHAs on ART has increased sharply from about 3,000 at the start of 2002 to 27,000 by end-2003,
and to 52,593 by February 2005. The program is financed in part by the Global Fund to Fight
AIDS, Tuberculosis and Malaria (GFATM), and in part with government budget. The number of
treatment sites increased from 112 in 2001 to 462 in early-2003, and to 841 by February 2005.
Table 2 shows the evolution of estimated cases of PHAs, AIDS cases, and access to public ART
in Thailand. As of end-2004, over 80% of those living with AIDS had access to public ART –a
remarkable achievement
Table 2: Estimated cases of people living with HIV/AIDS, AIDS cases, reported AIDS cases
in public hospitals, and access to public ART
1997
1998
1999
2000
2001
2002
2003
2004
751,235
740,349
719,765
649,564
665,344
635,057
603,942 572,484
Living with HIV/AIDS
59,752
65,333
68,311
68,677
67,057
64,832
62,871
61,394
Living with AIDS
1,095*
1,095*
1,095*
2,095*
2,095*
8,341*
27,158
52,593^
Patients in public ART
1.8%
1.7%
1.6%
3.1%
3.1%
12.9%
43.2%
81.4%
% of AIDS cases in public ART
4.1%
4.0%
4.0%
4.5%
8.5%
35.5%
122.6% % of reported AIDS in public ART
Source: The Thai Working Group on HIV/AIDS Projection (2001), Clinical Background Paper (2004), and MOPH (2004)
* Source: Follow-up to the Declaration of Commitment of HIV/AIDS (UNGASS) Country Report (2002)
^ Figure for February 2005.
1
GPO-vir is a single tablet 3 drug combination regimen (d4T+3TC+Nevirapine) produced by the
Government Pharmaceutical Organization (GPO).
2
Benefits of Prior Prevention Efforts
Successful implementation of NAPHA poses a significant challenge to the Royal Thai
government and Thai society. In a few years, as AIDS patients live longer with ART, the health
system will need to provide care not only to 10,000-20,000 new cases per year, but also to most
of those whose lives have been significantly prolonged by ART. Given the commitment across
all segments of Thai society, the country’s significant health system capacity, and the availability
of internal and external financing, Thailand has good prospects for meeting this challenge. Its
ability to even contemplate providing care to all those who need it, however, rests on the success
of its past prevention efforts.
20
10
20
05
20
00
19
95
19
90
19
85
Current HIV Infections in millions
In the absence of such past
Figure 2: Importance of Prior Prevention Efforts
successful national prevention
efforts, HIV infections –and
Thailand – Enormous current benefits of
hence AIDS cases —today would
prior prevention efforts
be much higher than they actually
10
are (Figure 2). We have
Red line represents what
estimated that in the absence of
might have been if
8
such efforts, Thailand would have
behaviors had not
changed
7.7 million HIV cases and
6
Infections
850,000 AIDS cases in 2005,
prevented
4
roughly 14 times more of each
than exist in reality. If we
2
suppose that Thailand would try
0
to offer ART to all of this much
larger number of AIDS patients,
its budget requirements would
Baseline
No Intervention
also be 14 times greater and
would continue to grow over the
Source: East-West Center and Thai Working Group projections, 2001
next decade. Thanks to its
substantial prevention efforts over the decade from 1991 through 2002, Thailand has avoided the
need to spend an additional $18.6 billion (745 billion baht) on treatment over the decade through
2012.
During the 1990s Thailand spent more than most countries on its HIV/AIDS program. Its total
budget expenditures on prevention and treatment combined over this period was a substantial
$434 million in 2002 dollars (17.3 billion baht). However, by averting the need to spend $18.6
billion dollars (745 billion baht) over the subsequent decade, each dollar (or baht) invested in the
1990s saved 43 dollars (or baht) in needed treatment expenditure in the subsequent decade. It is
doubtful than any other Thai government investment achieved such a high rate benefit-cost ratio.
The finance ministries of countries like India and China, where the HIV/AIDS epidemic is at an
earlier stage, should be aware of the high return to HIV/AIDS prevention campaigns when they
make intersectoral allocations of the government’s budget.
Even in Thailand, however, there is no room for complacency. Although policies have been
successful in lowering infection rates, prevalence of HIV in high risk groups is still high –
especially among those groups that were not explicitly targeted by past prevention efforts such as
IDUs or male sex workers. There is also evidence that the impact of past prevention campaigns is
waning. Recent rounds of the Behavioral Surveillance Survey (BSS) show that the percentage of
male conscripts reporting sexual relationships with commercial sex workers, after declining for
3
several years, has started to pick up again in 2002 and 2003. The same pattern is visible with
other female sex partners and among married conscripts who have extramarital sex. Condom use
among these male conscripts is not high: only 59% report consistent use of condoms with sex
workers; and only 25% do so with non-regular female sex partners. New risk behaviors by other
groups, such as youth, also need to be addressed.
Insurance and Care Coverage for PHAs
Thai health policy makers have been working to expand insurance coverage to the Thai
population while ensuring the financial soundness of the government health care system. In this
context, the government’s decision to finance AIDS care raises issues regarding the sustainability
of the overall health care financing system and whether AIDS care should be financed in the same
way as care for other health problems.
There are four main health insurance schemes in Thailand, covering nearly 100% of the
population: the Social Security Scheme (SSS) and Workmen’s Compensation Fund (WCF)
covering formal private sector workers; the Civil Servant Medical Benefit Scheme (CSMBS) for
government employees; and the “30-Baht” or Universal Coverage Scheme (UCS) for the rest of
the population. The different health insurance schemes are managed independently, with
different reimbursement mechanisms and separate reporting requirements for providers.
The different schemes offer slightly different coverage and quality of care for PHAs. The UCS
covers preventive and curative care for PHAs (treatment of all OIs), but does not cover ART nor
associated testing/monitoring. Access to ART for PHAs covered by the UCS is offered under the
NAPHA program, which is run as a separate vertical program under the MOPH. ART is
available for all PHAs who meet the eligibility criteria and are present for treatment at their
registered hospital (assuming the hospital has a treatment slot available, as in some regions of the
country there are waiting lists). The patient must pay for the first CD4 test (about 500 Baht); but
all monitoring and testing once the patient’s enrolled is covered by NAPHA, as well as the cost of
the drugs (in practice, however, hospitals exercise some discretion in asking patients to co-pay,
depending on an assessment of their means).
Until August 2004, NAPHA also covered access to ART for PHAs under the SSS. As under the
UCS, patients were required to pay for the first CD4 count, but all subsequent monitoring and
testing, as well as the price of the ART was covered by NAPHA (although again with discretion
on the part of the hospital as regards co-payments). All other OP and IP care for PHA was
covered by SSS. As of August 2004, the SSS includes access to ART as part of its care package
for PHAs. All SSS patients being treated under NAPHA are transferred to SSS (about 13,000).
Guidelines for treatment (including the choice of drug regimes for first line treatment) are
purported to be similar for SSS and NAPHA. The CSMBS covers all PHA care including ART,
and associated monitoring/testing.
AIDS Expenditure and Financing
According to the National AIDS Accounts (Teokul, Tangcharoensathien et al., 2004), total health
expenditure on HIV/AIDS increased from 2,996 million Baht in 2000 (US$74.4 million) to 4,188
million Baht in 2003 (US$101.3 million). The largest increases in spending during this period
came from the ART program (which more than tripled in spending) and from Outpatient care. In
4
response to this, the share of total AIDS expenditure going to ART increased from 20.3% in
2000, to 50.1%in 2003. Jointly, ART and OI account for 85.1% of total AIDS spending. The
share of spending going to prevention activities has declined sharply, from 9.3% in 2000 to 5.1%
in 2003, but the level has remained roughly constant in current prices (Figure 3).
Millions (USD)
Figure 3: National AIDS Budget Allocation during 1996-2004
60
50
40
30
20
10
0
1996
1997
Prevention
1998
1999
2000
Treatment & Care
2001
2002
Research & Mgt
2003
2004
Global Fund
Source: MOPH, National Prevention and Alleviation of AIDS Budget Allocation by the RTG.
The bulk of expenditures on HIV/AIDS have been financed from public budgetary sources, which
account for 65-80% of total AIDS expenditure during 2000-2003. The share of financing coming
from the two main health insurance schemes, SSS and CSMBS, has remained stable at 2.5% and
3% respectively for the same period. The share of spending by SSS is expected to increase as the
scheme covers ART treatment for SSS beneficiaries. Under this new SSS policy, around 13,000
patients are expected to shift from NAPHA program to SSS. Household out-of-pocket spending
has also played a significant role in financing AIDS expenditures, accounting for 27-28% of total
AIDS spending. Donor sources played a negligible role until 2003, when resources from the
Global Fund started to kick in, raising the share of financing by external sources to about 9% of
the total.
II. Measuring the Impact of ART Policy
The objective of ART policy is to improve the health of patients, allowing them to live longer
healthier lives. But ART policy has other effects, some of which are beneficial to the patient and
society, and some which are potentially harmful. A full economic analysis of ART would attach
a monetary value to all of the effects of ART, whether beneficial or harmful, in order to compute
the net-present value of the policy. Such an aggregated perspective is especially useful for
comparing the social rate of return to investments in treating AIDS patients to investments in
other sectors. The disadvantage of adopting the full economic approach lies in the fact that unit
values for healthy life years, years of orphanhood and other effects of the ART policy are hard to
establish or defend. Analysis based on controversial unit values will itself be controversial and
this controversy may distract from points that can be made without adopting these monetary
values. So in this analysis we have chosen to keep track of as many as possible of the effects of
5
ART, without attempting to aggregate them across categories. Our approach thus fits within the
framework of cost-effectiveness analysis rather than cost-benefit analysis.
Measuring the Effects
Since the objective of ART policy is to lengthen and improve the lives of the recipients, a natural
measure of the effectiveness of a policy is the number of life years it adds to the population.
Since the AEM model is a difference equation model, in which individuals are subsumed into
groups, it is not possible to directly measure the life years saved. The model, however, does
provide a count of the number of people beginning ART at each of the two recruitment points:
early and late. This report presents a calculation of the estimated number of additional life-years
that accrue to each individual who begins treatment, by whether that treatment is early or late.
We measure the effectiveness of an ART policy option by multiplying this estimate of per-patient
life-year benefit by the number of patients initiating each type of treatment in that year. This
gives a stream of annual benefits that continues over time as long as treatment itself continues.
Public policymakers need to consider not only the direct effects of ART policy on the patients
receiving ART, but also the indirect effects of ART on the creation of new cases of HIV infection.
There is increasing evidence, for example, that ART patients are significantly less infectious than
they would be in the absence of ART or with only mono- or duo-therapy. Assessing these
spillover effects of ART on people other than the patient is an indispensable part of designing
policy. Table 3 provides a classification of these indirect (or “external”) effects into biological
and behavioral effects on transmission. Within each of these categories, the effects could be
beneficial, by slowing transmission, or adverse, by accelerating it. The measure of the
importance of any of these effects is the rate of new HIV infections, or HIV incidence rate.
Biological
Behavioral
Type of effect:
Table 3. Possible effects of ART on HIV transmission
Direction of effect
Beneficial
Adverse
(Slow transmission)
(Speed transmission)
¤ Reduce infectiousness. ART may ¤ Select for resistance. Imperfect adherence
lower viral loads and may therefore to ART selects for resistant strains of the
lower the risk of transmission per
virus, which can then be transmitted.
sexual contact.
¤ Longer duration of infectivity. The greater
longevity of HIV infected people taking ART
has the unintended negative consequence of
increasing the period in which the patient can
transmit the virus.
¤ Encourage prevention, especially
¤ Off-setting behavior. People receiving
diagnostic testing. ART may
ART, and HIV positives and negatives in the
increase the uptake rates of
surrounding community, may engage in more
prevention activities, particularly
risky behaviors than they would if ART were
voluntary counseling and testing.
unavailable.
Source: M. Over, et al. (2004).
6
Measuring the Costs
Cost analysis of health programs typically distinguishes between fixed costs and variable costs.
The fixed costs are occasioned by the establishment of a health program, while the variable costs
are typically simply unit costs multiplied by the number of units of output. For the purposes of
projecting the costs of ART policy we have adopted the simplifying assumption that most
program costs will be related to the individual patient in the form of provider time,
pharmaceutical products, diagnostic tests and disposable paper and rubber products, and therefore
will not vary much with scale or scope. The exception we are making to this rule is the cost of
equipping a health care facility that is not a district hospital with the capacity to administer ART.
We assume that in order to qualify to manage one or more ART patients, any facility must train a
minimum number of providers in ART protocols and, in order to keep them abreast of the rapidly
changing technology of ART, must re-train those staff every year. This category of costs might
be called “recurrent fixed costs”. They recur every year as a function of the number of facilities,
but can be spread over all the patients at the facility.
III. The Effects of Thailand’s ART Policy
In order to estimate the impact of NAPHA and then the cost-effectiveness of various
modifications of NAPHA, we must model how the specific changes introduced by NAPHA
influence the behavior of patients and providers. Our approach is to construct a model of the
links between government instruments and policy outcomes. We do this in five steps.
First, we model the link from
Figure 4: Policies to epidemiology to performance
the two primary policy
instruments, price and
availability (or supply), to the
Modeling: Policy to Impact
distribution of patient demand
for care. Second we project the
POLICY INSTRUMENTS
MODEL INPUTS
MODEL OUTPUTS
COST & IMPACT ANALYSIS
evolution of prices and
Demand for ART
Biological
HIV cases
•Unit Cost Analysis
availability into the future and
Price
Time to death
Annual deaths
Cost of OI treatment
Distance
Shifts from 1 to 2 line
VCT by risk group
Cost of ART
compute the projected
Quality
Transmission reduction
Sympt. on 1 line ART
Cost of PHA support
Supply for ART
Behavioral
Sympt. on 2 line ART
•Cost projections
Available ART slots
Dropouts in each arm
Asympt. on 1st line ART
•Cost-effectiveness Analysis
distribution of demand across
Demand for VCT
Risk behavior
Asympt. on 2 line ART
Cost per death averted
Price
Condom use
Cost per life year saved
treatment options. Third, we
Distance
Needle sharing
•Financial Analysis
Quality
Impact
on AIDS budget
apply the expected demand to
Supply for VCT
Impact on health budget
Prop. of pts in each arm
Available VCT slots
Financing
No.
of
pts
in
each
arm
the Thai population of eligible
infected people (as projected by
an updated version of the Asian
Epidemiological Model (AEM))
COST & IMPACT
Models
ASIAN EPIDEMIC MODEL
SHEETS
of behavior
in order to deduce the future of
(Proprietary AEM)
(Excel)
(Excel)
ART utilization. Fourth, we
estimate the direct and spillover
effects of ART utilization on
Source: Authors’ construction.
health and HIV incidence; and
fifth we apply unit costs to
estimate the financial burden of the NAPHA policy. These five steps are summarized in Figure 4.
st
nd
st
nd
nd
7
Projection Scenarios
The impact of a policy choice can only be defined in comparison to what would have happened in
the absence of this choice. This alternative scenario, called a “baseline” or “counterfactual”, is a
projection of the future course of AIDS treatment had the Royal Thai government not introduced
its expanded NAPHA program. There were several alternative baseline scenarios that could have
been chosen (cells (a), (b) and (c) in Table 4), each corresponding to a different combination of
public financing of ART and government subsidization of the production and sale of low-cost
ART. The chosen baseline corresponds to cell (a): what would have happened had the
government kept only its previously existing (pre-2001) voluntary program, with only branded
drugs available.
The impact of NAPHA is obtained by comparing outcomes from cell (a) to those from cell (d).
The total impact could be separated into a part due to the availability of low-cost generic ART
and a part due to the public finance of ART provision. Such a deconstruction would enable us to
attribute portions of the benefits of NAPHA to each of its two components and a portion to
synergy between them. We do not undertake that deconstruction here.
Table 4: Potential baseline scenarios or “counterfactuals” to NAPHA
No
Govt. to produce and
sell low-cost ART
(GPO-vir)
Yes
Government to finance ART publicly
No (private out-of-pocket only)
Yes
(a) Baseline. No government
(b) Provide subsidized public
intervention – voluntary program production with no possibility
only, too small to make a
of alternative supply channels
difference
(buyers clubs etc)
(c) GPO produces and markets
GPO-VIR at current prices (less
than $1/day), but government
does not expand public delivery
of ART through the public
health system beyond the ATC
program
(d) NAPHA (current form and
alternative versions including
stimulating VCT for earlier
recruitment, and introducing
demand-side incentives to
increase adherence)
In addition to the NAPHA policy scenario described above, the report considers two
enhancements to NAPHA and a third policy which would combine these two enhancements
(Table 5). The enhancements are chosen to address what are perceived by knowledgeable Thai
and international observers to be potential weak points in the NAPHA program and indeed in all
publicly financed and provided ART programs worldwide.
Early analyses of the effectiveness and cost-effectiveness of publicly provided ART assumed that
many HIV-infected patients would be recruited to treatment when their immune systems first
drop below an eligibility threshold, so that the benefits of ART would be maximized. Experience
in Thailand as well as in several other countries (e.g. Malawi, Botswana, Brazil, and OECD
countries) shows, however, that the vast majority of patients are identified as ART eligible only
when their opportunistic illnesses lead them to the hospital, when their CD4 counts are already
well below the threshold at which they would most benefit from care. It is thus useful to analyze
an alternative version of NAPHA which would include a much more vigorous promotion of
8
voluntary counseling and testing (VCT) in an effort to attract patients into treatment when they
first become eligible for it.
A major challenge for ART programs will be to attain and sustain high levels of adherence among
their patients. Ministry-sponsored training programs for public sector ART providers are
currently teaching the importance of adherence. But experience around the world suggests that,
as ART treatment is scaled up, it will be increasingly difficult to attain high levels of adherence
among new patients and to sustain them among all patients. One promising approach with which
Thailand has already experimented is to subsidize, and to facilitate the organization of, NGOs that
provide emotional, physical and sometimes even financial support to patients. In this report, we
refer to public sector delivery which has been strengthened by the addition of these “demand
enhancing” programs as “augmented public” delivery of ART. Our “Augmented (D3)” scenario
is intended to capture the incremental benefits and costs of such a program.
We also model a “Both (D4)” program, which includes the costs of both expanded VCT and
“augmented” adherence and models a synergistic benefit between them.
Table 5. Policy scenarios for the NAPHA program
Encourage adherence
through demand-side
incentives such as
PHA groups,
accompagnateurs,
conditional transfers,
etc.
No
Yes
Encourage VCT and early recruitment into ART
No
Yes
(D1) Current implementation (D2) Earlier recruitment
of NAPHA program
through VCT (at higher CD4
(recruitment of mainly
counts), without improved
symptomatic HIV through
adherence
the public health system)
(D3) Improved adherence
(D4) Improved adherence
without earlier recruitment
and earlier recruitment
(keep current recruitment of
(recruit earlier through VCT
symptomatic HIV via public
at higher CD4 counts)
health system)
The Asian Epidemic Model
The Asian Epidemic Model (AEM) is a difference equation model that projects the dynamic
patterns of HIV epidemics in Asian settings. Developed by Tim Brown and Wiwat
Peerapatanapokin of East-West Center, in collaboration with the Thai Epidemiological Working
Group and the Thai Ministry of Health, the model is sufficiently disaggregated to benefit from
available data on risk behavior and HIV prevalence of all the important risk groups within the
Thai population (The Thai Working Group on HIV/AIDS Projection 2001; Brown and
Peerapatanapokin 2004). The model has three major transmission modules (heterosexual contact,
needle sharing and homosexual contact) and eight risk groups. The biological parameters of the
model have been calibrated so that the model’s projected prevalence rates match observed rates
by risk group.2 Such detailed fitting is rare among models of HIV epidemics partly because most
countries outside Thailand have too little data to permit such comparisons.
2
This is the meaning of the term “semi-empirical” that the published papers use to describe the model.
9
The previous version of this model did not include the effects of ART on the longevity of people
with HIV, on their likelihood of transmitting HIV or on the development and spread of drug
resistant strains of the virus (The Thai Working Group on HIV/AIDS Projection 2001). The new
version of the model, developed for this report, allows for: (a) detailed modeling of early VCTbased recruitment of asymptomatic patients (at higher CD4 counts) to increasingly substitute for
late recruitment of symptomatic patients through the health system (typically at much low CD4
counts); (b) different treatment arms (pure public vs. augmented public vs. private); and (c)
progression into second line therapy (Brown and Peerapatanapokin 2004).
IV. Costs and Resource Needs for ART
Costs of ART can be defined in many ways, such as costs to the public sector, to individual
patients, and to the society. In order to evaluate the various policy options for expanding public
provision of ART in Thailand, we adopt the perspective of and estimate the costs to the public
sector. Average costs of ART per patient are estimated based on types of treatment regimes (first
line therapy and second line therapy), modes of service delivery (public, augmented public and
private service delivery), and stages of the disease (asymptomatic and symptomatic HIV).
Specific cost components included in estimating average costs of ART per patient are: ARV
drugs, lab tests and monitoring; treatment of OIs; and PHA support. Cost data were obtained from
existing studies in Thailand, both published and unpublished, and informal consultations with
local and international experts.
Costs of ARV drugs and monitoring
Table 6 summarizes costs of various regimens currently available and recommended by Thai
MOPH and WHO in their treatment guidelines. The annual costs of ARV drugs vary significantly
between first line and second line regimens, ranging from 14,400 baht (using GPO-vir) to
273,864 baht (using expensive PIs) per patient per year. The average cost of first line ART
regimen is estimated at 19,271 baht (US$ 481.8) per patient per year, using weighted average of
three categories of ART drug regimes under the MOPH treatment guideline. 3 The average cost of
second line regimen is estimated around 270,000 baht (US$6,740) per patient, costing 14 times
more than the average cost of first line regime.
3
Weights are distributed by 80%, 15%, 5%, for (1), (2), and (3) ART regimes respectively.
10
Table 6. Costs of ARV drugs per patient by types of regimens in Thailand
(1USD = 40 baht)
Monthly Cost
Annual Cost
ARV drugs
Baht
USD
Baht
USD
First line regimens (MOPH guideline)
(1) 3TC+d4T+NVP
1,200
$30.0
14,400
$360.0
2,579
$64.5
30,948
$773.7
(2) d4T+3TC+EFV
AZT+3TC+EFV
3,819
$95.5
45,828
$1,145.7
AZT+3TC+NVP*
2,400
$60.0
28,800
$720.0
(3) d4T+3TC+IDV/r
3,500
$87.5
42,000
$1,050.0
AZT+3TC+IDV/r
4,740
$118.5
56,880
$1,422.0
1,606
$40.1
19,271
Average cost
$481.8
Second line regimens (WHO guideline)
ABC+ddI+LPV/r
22,822
$570.6
273,864
$6,846.6
ABC+ddI+SQV/r
22,094
$552.4
265,128
$6,628.2
22,458
$561.5
269,496
Average cost
$6,737.4
Source: Bureau of AIDS, TB, and STI, MOPH, 2004. Duncombe, C. (2004) Section Two in the
Clinical Background Paper, 2004. The Government Pharmaceutical Organization, Price List, 2004
Note: Costs of ARV drugs are based on the lowest prices available (either generic or branded drugs) in
Thailand, as of September 2004.
* The GPO is currently in the production process of a fix-dose combination of GPO-Z (AZT, 3TC,
and Navirapine). The cost of GPO-Z is approximately at 1400 baht (US$35) per month.
In addition to the cost of ARV drugs, there are significant costs associated with the provision and
monitoring of ART treatment. The costs of outpatient and inpatient services are not negligible as
utilization of medical services increases at the time of initiating ART treatment. A recent study4
evaluating medical resource utilization for ART estimated that the average cost of hospital
services (including OPD and IPD services, but excluding ARV drugs, lab tests, and OI
medications) is around 7,700 baht (US$193) per patient per year in public hospitals, ranging from
12,850 baht (US$321) in university teaching hospitals to 5,340 baht (US$134) in community
hospitals (Supakakunti, Phetnoi et al. 2004). The cost of CD4 test by standard flow cytometry
varies from 200 baht to 800 baht with the median cost of 500 baht (US$12.5), depending on the
institution and the volume of testing. The cost of HIV RNA (viral road) test is significantly
higher, averaging at around 3,500 baht (US$88) per test. A basic safety chemistry panel (SGOT,
creatinine, glucose) costs around 100 baht (Duncombe 2004 and Gold 2004). In addition to the
routine monitoring tests, patients incur sets of screening tests (i.e., CD4 count and HIV antibody)
prior to initiation of ART treatment. These initial screening tests cost around 1,100 baht (US$28)
per patient.
Costs of OI treatment
Prior to the introduction of the NAPHA program, treatment for OIs comprised the bulk of
treatment cost in national AIDS expenditure. More than 20 different infections are associated
with severe immune depletion. Even though the costs of OI treatment vary significantly
4
The study was conducted, jointly by WHO-Thailand and the Center for Health Economics at
Chulalongkorn University, at 32 public hospitals across 4 regions in Thailand to evaluate economic costs
associated with NAPHA program. The study specifically followed 380 patients between October 2002 and
December 2004 to measure the medical resource utilization at public hospitals.
11
depending on the type of infections and available treatment options, there are several types of
infections observed most often among symptomatic HIV patients. The OIs that are commonly
observed in Thailand are tuberculosis (TB), pneumocystis carinii pneumonia (PCP) cyriptococcal
meningitis, cytomegalovirus infection and others (Ratanasuwan, 2004; Supakankunti, et al. 2004).
Existing studies on OI treatment from Thailand were reviewed to estimate the average cost of OI
treatment per patient. The average costs of OI treatments vary across the studies, ranging from $64 to
$206, with the average cost of $151 per patient.
Costs of PHA groups
PHA groups have long played a major role in providing care and support needed for HIV patients
in Thailand. Many of the public hospitals under the NAPHA program work with PHA groups
who provide counseling, information, home visits and other supports to PHAs. It is expected that
continuous care and support from PHA groups will become increasingly important in expanding
public provision of ART; specifically by supporting patients in their adherence to ARV. Success
of community involvements in HIV/AIDS care through PHA groups and community based
organizations has been well documented in Thailand, while very little has been studied about
their resource requirements and financial sustainability. With the help of MSF-Thailand, and
drawing on their experience with PHA support groups nationwide, we obtained some preliminary
estimates of the costs of PHA support to improve adherence. These estimates suggest that
providing PHA support to improve adherence costs approximately 3,100 baht (US$78) per
patient; or in other words, adds some 8-9% to the total cost of ART per patient per year (Masaki,
2004; interview with David Wilson, MSF).
Average cost of ART per patient
Based on the above estimates, the annual average cost of ART using first line therapy is estimated
at around 33,000 baht (US$825) per patient (Table 7). The costs of ARV drugs and lab
monitoring represent nearly 60% of the total ART cost when first line therapy is used, and
increases to 95% of the ART costs when patients are on second line therapy.
Table 7. Annual cost per patient by types of drug regimens
Annual Cost per patient
Cost Items
(1) ARV drugs
(2) Lab tests
(3) OI treatment
(4) OPD service
(5) IPD service
(6) ARVs + lab tests
(7) Hospital services
(8) Total ART cost
(1) + (2)
(4) + (5)
(3)+(6)+(7)
1st line
THB
USD
18,847
$471.2
1,210
$30.3
4,815
$120.4
2,773
$69.3
6,041
$151.0
20,057
$501.4
8,815
$220.4
33,688
$842.2
2nd line
THB
263,567
1,210
4,815
2,773
6,041
264,778
8,815
278,408
USD
$6,589.2
$30.3
$120.4
$69.3
$151.0
$6,619.4
$220.4
$6,960.2
Source: Supakankunti, et al. (2004). Costing of “The National Access to Antiretroviral Programs for People living with
HIV and AIDS” in Thailand. Chulalongkorn University and WHO, Thailand.
Note: The presented cost per patient is an average cost of provincial and community hospitals.
12
V. Main Findings
1. NAPHA is cost effective and yields large benefits in terms of life-years saved.
•
By the year 2015 the NAPHA policy will have added about 220,000 people per year to
the living population. Even at the end of the projection horizon, when the Thai AIDS
epidemic is predicted to slow, the NAPHA policy will be saving about 190,000 life years
each year (Figure 5). By keeping people alive longer, NAPHA will be associated with an
increase in the number of HIV infected people in Thailand, and with a significant
increase in the number of PHAs on treatment.
•
The total cost of NAPHA with second line reaches a ceiling at US$500 million per year
in 2020. Beginning in 2010, expenditures on second line start to account for more than
one-half of total spending. By the end of the projection, second line therapy for one
quarter of all the patients is absorbing three-quarters of the treatment budget (Figure 6).
•
At a conventional discount rate of 3%, the cost per life year saved for the NAPHA policy
is $2,144, only slightly greater than Thailand’s 2002 gross national income per capita of
$2,000.
•
NAPHA with first-line only is more affordable and more cost-effective, but also yields
significantly lower benefits in terms of life-years saved (Figure 7).
13
Figure 5: Benefit (Life Years Saved) and Costs of NAPHA relative to Baseline
(Costs are in millions of 2004 US dollars)
LYS
250,000
ART Cost (net) and Benefit (LYS) in Scenario D1
- Compared to Scenario A -
in million
600
500
200,000
400
150,000
LYS
300
Net Cost of ART
100,000
200
50,000
100
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
0
Figure 6: After 2010, most costs are for second line therapy
(Millions of US$)
Millions
Total Cost of Public ART (NAPHA)
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
$500
$450
$400
$350
$300
$250
$200
$150
$100
$50
$0
Cost of Public ART_1 line_asy
Cost of Public ART_2 line_asy
Cost of Public ART_1 line_sym
Cost of Public ART_2 line_sym
14
Figure 7: Program with first line only is more cost-effective
NPV of Cost per LYS by Scenario
- discounted at 3% $3,000
$2,500
$2,000
$1,500
$2,145
$1,000
$500
$736
$0
NAPHA_1only
NAPHA_1only
NAPHA_1+2line
2. Expanded policy options increase life years saved (LYS) but are slightly less-cost
effective
•
Adding early recruitment and enhanced adherence buys additional life years. The
expanded VCT, augmented adherence and “Both” policies would save respectively
18,000, 50,000 and 60,000 additional life years in 2020, on top of the 210,000 LYS
generated by NAPHA alone. Thus for the year 2020, the alternative policies offer the
possibility of improving the benefits by almost 30 percent (Figure 8).
•
These expanded policies, however, also involve additional costs. Of all four policies, the
current NAPHA policy (D1) is the most cost-effective. The second most cost-effective is
the Augmented policy. This is not surprising since it achieves two or three times as many
incremental life-years saved at roughly the same cost as the VCT scenario. Because it
combines the two “pure” enhancement strategies, the cost per year of the “Both” scenario
lies between the costs per year of the other two scenarios (Figure 9).
15
Figure 8: Projected Annual LYS under Alternative Scenarios relative to baseline)
Additional LYS
300,000
250,000
200,000
150,000
100,000
50,000
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
0
Scenario D1
Scenario D2
Scenario D3
Scenario D4
Figure 9: Cost Effectiveness of NAPHA and alternative scenarios relative to Baseline
NPV of Cost per LYS by Scenario
- discounted at 3% $3,000
$2,600
$2,342
$2,200
$2,145
$2,184
$2,243
$1,800
$1,400
$1,000
Scenario D1
D1
ScenarioScenario
D2
Scenario
D3
Scenario D4
3. Public financing will help assure equitable access to ART for poor patients
•
Suppose that Thailand had reduced the price of first-line ART, by authorizing the
production of GPO-Vir, but had refrained from subsidizing treatment. For the top half of
the households in the income distribution, first-line ART could be affordable via user fees
(Figure 10). Even for the poorest half of the households, the $842 cost of first-line
therapy compares with the medical expenses of the sickest households for a single year.
16
The problems for the poorest households are likely to be caused by two unusual features
of the cost of treatment. First, it must continue for the rest of the patient’s life. For
households in the lowest 80 percent of the income distribution that might be able to raise
the resources to pay the $842 for one year, the second and third year will become
increasingly onerous. Second, laxity in treatment will lead to treatment failure, the
development of resistant strains of the virus, the spread of those resistant strains to others
and the requirement that the patient move to second-line therapy.
•
While it is conceivable that the cost of first-line therapy could be partially financed with
user fees, second-line therapy is much more expensive, exceeding total household income
for forty percent of the population. A large proportion of those on first-line therapy will
eventually need second-line therapy, and would not be able to afford it without public
support.
Figure 10: Affordability of ART by Income Level
Affordability by Income Lev els
$45,000
$40,000
Mean household
incom e
Nonfood expenditure
per household
Medical expenditure
per household
Cost of ART (2nd line)
$35,000
$30,000
$25,000
$20,000
Cost of ART (1st line)
$15,000
$10,000
$5,000
$0
Q1
Q2
Q3
Q4
Q5
Income Ouintile
4. Public financing can strengthen positive spillovers and limit negative spillovers of ART
•
ART may be used to increase the uptake rate for prevention activities, especially
voluntary counseling and testing. But this requires greater integration of treatment and
prevention efforts that currently exists in Thailand.
•
Poor adherence to first-line therapy will speed the development of resistance to those
drugs and hasten the day when the patient must move to second-line therapy. Public
intervention to support adherence can limit the spread of resistance virus. From a social
as well as an individual perspective, adherence support mechanisms such as the
“augmented” public care we model in this report are likely be cost-effective as well as
therapeutically beneficial.
17
5. If the success of ART rollout makes people or the government complacent about
prevention, future costs could rise substantially.
•
If the availability of ART leads people to reduce risk behaviors such as drug injecting and
unprotected sex, the cost-effectiveness of ART is improved by about 9 percent and future
government expenditures on ART will go down by $926 million dollars or by 14 percents.
•
On the other hand, if the availability of ART leads people to increase their risk behavior
back to its levels in the early 1980s, the cost per life year saved will triple from $2,145 to
$6,243 (from 85,800 baht to 249,720 baht). There will be a similar increase in future
government expenditures.
6. Future government expenditures on ART and the lives it will save are highly sensitive
to negotiated agreements on the intellectual property rights for pharmaceuticals
•
Since the drugs used in second-line therapy are patented, produced and sold by
multinational pharmaceutical corporations, Thailand must either pay the high prices
demanded by those monopolies or exercise its rights under World Trade Organization
treaties to grant a “compulsory license” for the manufacture of the drug subject to
negotiated royalties.
•
Because Thailand stands to gain a great deal from bilateral agreements to reduce trade
barriers with trading partners like the United States, the RTG may be tempted to
relinquish its rights to grant compulsory licenses for AIDS drugs in exchange for
proffered trade advantages. The report finds that the cost of such concessions would be
large. For example, by forgoing compulsory licensing to reduce the cost of second-line
therapy by 50%, the RTG would raise the cost per life-year saved of the NAPHA
program by 45% (from $1,476 to $2,145) and increase its future budgetary obligations by
1.8 billion discounted dollars (71 billion discounted baht) through the year 2025.
•
The size of royalty payments that the WTO mandates to accompany compulsory
licensing is indeterminate and subject to negotiation. Thailand could enhance its
bargaining power by coordinating its negotiations with other middle and low income
countries.
VI. Conclusions and Recommendations
•
In its current form, Thailand’s NAPHA program is affordable. Under the model’s
assumptions it is also cost-effective. Furthermore, although the two enhanced policies we
suggest (early recruitment through expanded VCT and improved adherence via PHA
groups) are less cost-effective, they are still a good bargain, particularly if BOTH are
enacted.
•
Much of the cost of ART over the long-term is associated with provision of second line
treatment. One way to limit the potential financial burden is for the Thai government to
make explicit the scope of its commitment to providing public ART: is it a limited
commitment to provide only first-line treatment, or a more open commitment to provide
whatever level of treatment is required by the patient? Estimates of cost-effectiveness
18
show that a version of NAPHA that includes only first-line drugs is much more costeffective, at only $736 per life year saved, than the policy with second line; however,
NAPHA with second-line saves many more life years.
•
A second way for the RTG to limit its expenditures on second-line therapy is to grant
compulsory licenses for the manufacture of patented second-line pharmaceutical products.
Doing so will require high-level political resolve based on an accurate understanding of
the costs to Thailand of trade concessions on this issue.
•
Although affordable, expanding ART represents a long-term financial commitment that
must be integrated into the budget processes. Once the Thai government has committed
to starting a patient on ART, this becomes an entitlement that cannot be sacrificed to
budget cycles without incurring large negative externalities. Sustaining the program will
require a significant increase in the total health budget, to avoid other health programs
being squeezed by ART. Alternatively, the Government may need to explore other
financing mechanisms – including greater use of health insurance schemes.
•
Although NAPHA may be affordable, Thailand must be careful to maintain quality
management as it scales up and to sustain that quality over twenty years. This is a very
long run commitment.
•
The biggest challenge for Thai policymakers will be how to resist complacency and
instead build a synergistic relationship between treatment and prevention. This may
require devolution of responsibility for both treatment and prevention to provinces or
below so that government units that succeed with prevention will benefit from the saved
treatment costs.
•
Finally, the cost of $2,145 per life year saved through ART may be much more than
Thailand would have to spend to save life years with other interventions. The study
recommends that Thailand accompany its expansion of the ART program with vigorous
investigation of other promising opportunities to improve health cost-effectively. Prime
candidates among these alternatives would be inexpensive HIV prevention programs,
including condom distribution and peer education. To our knowledge, no study of the
cost-effectiveness of condom distribution has ever been done in Thailand. Expansion of
immunization programs, of traffic safety and trauma management, of nutrition programs
and of water supply are all candidates for cost-effective interventions which would save
life years at probably much less than $2,000 per year.
19
REFERENCE
Brown, T. and W. Peerapatanapokin (2004). Adding HAART to the Asian Epidemic Model,
presentation at the Workshop on "Expanding Access to ART in Thailand: achieving
Treatment Benefits and Promoting Effective Prevention". Bangkok, Thailand.
Brown, T. and W. Peerapatanapokin (2004). The Asia Epidemic Model: a process model for
exploring HIV policy and program alternatives in Asia.
Duncombe, C. (2004). “Clinical Aspects of HIV/AIDS Care in Thailand from a Clinical Research
and Community-based perspective”, prepared as an input to the Clinical Background
Paper for this study.
Gold, J., C. Duncombe, et al. (2004). Clinical Background Paper for Expanding Access to ART in
Thailand Report, MOPH/The World Bank.
Masaki, E. (2004). “Evaluating Financial Implication of ART Policy in Thailand”, prepared as a
background paper for this study.
Over, M, P. Heywood, J. Gold, I’ Gupta, S. Hira, E. Marseille. (2004). HIV/AIDS Prevention and
Treatment in India: Modeling the Costs and Consequences. Washington, World Bank.
Phongphit, S. (2004). Behavioral Background Paper for Expanding Access to ART in Thailand
Report. Bangkok, MOPH/The World Bank.
Ratanasuwan, W. (2004). “Clinical aspects of HIV/AIDS care from a University Hospital
perspective”, prepared as an input to the Clinical Background Paper for this study.
Supakakunti, S., W. Phetnoi, et al. (2004). Costing of "The National Access to Antiretroviral
Programs for People Living with HIV and AIDS" in Thailand. WHO Collaborating
Centre for Health Economics, Chulalongkorn University
Thanprasertsuk, S. (2004). HIV/AIDS in Thailand: Current Situation, Successes and Remaining
Challenges. Bangkok, Department of Disease Control, MOPH.
Thanprasertsuk, S., C. Lertpiriyasuwat, et al. (2004). Situational Analysis of the Process for
Developing ART Policy by the Royal Thai Government (background paper for the
Expanding Access to ART in Thailand Study). Bangkok, MOPH/The World Bank.
The Government Pharmaceutical Organization (2004). Price List, 2004
The Thai Working Group on HIV/AIDS Projection (2001). Projections for HIV/AIDS in
Thailand: 2000-2020, Karnsana printing press.
Wannamethee, S. and S. Sirivichayakul (1998). International Journal of Epidemiology 27: 289295.
20
Wilson, D. and N. Ford (2004). “Challenging and Cooperating with Government: community
activities supporting access to care and treatment for people with HIV/AIDS in Thailand”,
prepared as an input to the Clinical Background Paper for this study.
World Bank (2000). Social Monitor Thailand: Thailand's Response to AIDS: Building on Success,
Confronting the Future. Social Monitor: 1-63.
World Bank, T. (1999). Confronting AIDS: Public Priorities in a Global Epidemic. New York,
Oxford University Press.
21